Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Friday, September 30, 2011

A report on the link between suicide and physical ill health has found that one in 10 people who take their own life is chronically or terminally ill.

The report, by think tank Demos, is one of the first such comprehensive studies to look at the links between suicide and physical ill health. It says that the figure, which came from coroners and primary care trusts (PCTs), is likely to be a substantial underestimate because coroners do not always include the relevant health information with their inquest reports.

Demos believes that the findings provide strong evidence that people with chronic and terminal illnesses should be regarded as a high risk group for suicide and should be given better “medical, practical, and psychological support.”

Demos believes that the findings provide strong evidence that people with chronic and terminal illnesses should be regarded as a high risk group for suicide and should be given better "medical, practical, and psychological support."

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The government launched a consultation on suicide in July which identified five high risk groups for suicide: people in the care of mental health services (1200 suicides a year); people in the criminal justice system (80 suicides in prison a year); adult men aged under 50 (2000 suicides a year); people with a history of self harm (950 suicides a year), and occupational groups such as doctors, nurses, and farmers.

There were 4390 suicides in England in 2009, which, using Demos's calculation, would mean that more than 400 of these were among people with a chronic or terminal illness.

Demos believes that this group should be identified as high risk.

<snip>

Louise Bazalgette, author of the report, said it was important that doctors treating people with a chronic or terminal illness were aware of the issue.

"Doctors should be thinking about the possibility that a person with chronic health problems may be depressed and struggling. They should ask them if they ever feel suicidal," she said.

<snip>

Simon Gillespie, chief executive of the Multiple Sclerosis Society, said: "There is a big difference between someone wanting to end their life having explored and received every care option, and someone giving up hope because they feel they have nothing available to them. The right care and support can make a huge difference to an individual's life."

Clare Wyllie, head of policy and research at the Samaritans, said it was important that a suicide prevention strategy was implemented locally.

"It is vital that commissioners of local NHS, social care and public health services recognise that poor physical health and poor mental health are often closely linked [and] that depression is often undiagnosed in people with poor physical health," she said.

Thursday, September 29, 2011

A sophisticated new camera system can detect lies just by watching our faces as we talk, experts say.

The computerised system uses a simple video camera, a high-resolution thermal imaging sensor and a suite of algorithms.

Researchers say the system could be a powerful aid to security services.

It successfully discriminates between truth and lies in about two-thirds of cases, said lead researcher Professor Hassan Ugail from Bradford University.

The system, developed by a team from the universities of Bradford and Aberystwyth in conjunction with the UK Border Agency, was unveiled today at the British Science Festival in Bradford.

This new approach builds on years of research into how we all unconsciously, involuntarily reveal our emotions in subtle changes of expression and the flow of blood to our skin.

We give our emotions away in our eye movements, dilated pupils, biting or pressing together our lips, wrinkling our noses, breathing heavily, swallowing, blinking and facial asymmetry. And these are just the visible signs seen by the camera.

Some day care centers in Sweden are starting to use GPS and other electronic devices to keep track of kids when they go on supervised outings, according to an Associated Press report from Stockholm on Wednesday. Some have welcomed the idea as a practical solution, while others say it raises ethical concerns and invades children's privacy.

Par Strom, an author and commentator who specializes in the evolution of IT and its consequences for businesses, individuals and society, told Swedish news agency Tidningarnas Telegrambyrå (TT) he could see both sides of the argument about using technology to track kids, and was personally in two minds about it.

"On the one hand I can see the practical advantages in some situations. At the same time you get children used to constant surveillance at a very young age," said Strom.

The concerns are sufficient to raise the interest of Sweden's Data Inspection Board, who say they are likely to investigate the matter. The Board works to protect individual privacy in the information society. Their team leader, Eric Janzon, said the system could be "quite harmless", or it could "affect aspects of privacy".

For instance, there could be problems around storing personal data, or details of a person's whereabouts.

"It depends on what kind of information you feed into the system and the purpose of the use," said Janzon.

And even if it is initially developed for a good purpose, it could later be misused, he added.

Some parents are concerned that the technology is a means to replace staff at day care centers. Others are also worried about the ethical implications, and whether putting children under close surveillance could affect their sense of privacy as they get older.

But the day care centers appear to see it as a very useful practical device.

One day care center principal told the Associated Press they use the devices when they take the children on supervised excursions in the forest. The children wear a special vest that incorporates a transmitter, allowing staff to see where they are on a screen.

Monica Blank-Hedqvist, who runs a center in the city of Borlange, said the system is "excellent, it has been only positive for us".

She said they use it as extra security: they have three supervisors for 20 children, and the system quickly tells them when any children stray too far.

One of the companies supplying GPS devices is Purple Scout. Their spokesman said they did not store personal information, and they see the trackers as an aid to staff, not a replacement. They are currently testing their system at a day care center in the south of Sweden, but already have orders from many private centers, he said.

But some parents would prefer the money was used to pay for more staff. That was also the opinion of Malin Wollin, a columnist with the Swedish tabloid Aftonbladet. Wollin, who has three children, said it was a shame the money and energy was not going on salaries instead, noting that technology can sometimes "play up": anyone who has a cell phone or a computer knows this, she said.

The idea of tracking kids with GPS is not new, and has been raising controversy ever since the devices started appearing on websites, with benefits statements designed to bring peace of mind to anxious parents.

Wednesday, September 28, 2011

She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen.

She took a sip of her cocktail. The session began.

Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: “I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!”

And, she added, “I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session.”

Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans’ health care facilities and rural clinics — all supervised sites.

But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.

One third-party online therapy site, Breakthrough.com, said it has signed up 900 psychiatrists, psychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: “Web Therapy,” the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer.

“In three years, this will take off like a rocket,” said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. “Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can’t replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed.”

The pragmatic benefits are obvious. “No parking necessary!” touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable?

Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day’s drive away. But he was willing to use Skype with long-distance patients. She was game.

Now she prefers these sessions to the old-fashioned kind.

But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness?

The number of physicians using sites such as Facebook and Twitter has grown so quickly that Gabriel Bosslet, MD, realized the moment his study on physician social media use appeared in June that it already was out of date.

The data, collected by Dr. Bosslet between February and May 2010 and posted more than a year later on the Journal of General Internal Medicine site, found that 41.6% of doctors use social media sites.

However, between April and May 2011, research and consulting firm Frost & Sullivan found that 84% of doctors use social media for personal purposes. Then in August, nearly 90% of physicians reported that they used at least one social media site personally, according to a survey by the online physician learning collaborative QuantiaMD.

By those numbers, physicians are well ahead of the general adult population -- 65% of the general public use social media, according to a study published in August by the Pew Internet & American Life Project.

"The rise in social media has been so meteoric," said Dr. Bosslet, an internist at Indiana University Health and an affiliate faculty member at the Charles Warren Fairbanks Center for Medical Ethics in Indianapolis, which sponsored his research. The time that passed between data collection to his study's results being posted was like a "generation later," he said.

However, although physicians appear to be embracing social media, they are still feeling their way around it. According to QuantiaMD, 87% of physicians make personal use of social media, but a lesser amount, 67%, use it professionally. And one thing that hasn't changed during those 18 months is the lack of patient-physician communication on social media.

One-third of the QuantiaMD survey respondents said they had received a friend request from a patient on Facebook. Three-quarters of the physicians declined those invitations.

"There is a real reticence on the part of many physicians to use social media, or even email for that matter, to communicate with patients," said Nancy Fabozzi, health care market research and competitive intelligence specialist with Frost & Sullivan. Not only are physicians worried about liability and privacy issues, but also "there's not enough hours in the day, quite frankly," she said.

Even if some physicians themselves are not online, their names, comments on their style of practice, and complaints or compliments about them probably are.

All of the online content devoted to a particular physician could negatively impact his or her reputation, and subsequently his or her business, if steps aren't taken to manage that content and -- when necessary -- defend it. This is often referred to as online reputation management.

Online reputation management has become big business, as evidenced by the number of radio and online ads offering to help physicians. But physicians can manage their own reputations, help build positive ones, and prevent negative content from turning into a crisis that needs to be dealt with professionally.

As quickly as online content can spread, especially in the age of social media, experts say online reputation management should be a key component to any business plan.

"The best defense in these cases is good offense," said Scott Sobel, president of Media and Communications Strategy, a Washington-based public relations firm specializing in crisis management.

Christian Olsen, vice president of Levick Strategic Communication's digital and social media practice, said social media has changed the dynamics of reputation management, because in addition to physicians communicating with their patients, their patients are now communicating with one another on social media websites.

For most physicians, there are five simple steps they can take to manage and maintain a good reputation online. For others, managing their online reputations may require more time and expertise than they have available.

One: Google yourself

Olsen said many make the mistake of thinking that because they don't have a website or are not involved in social media they are not online. "It just means your voice is not being heard in a conversation about you," he said.

The first step in managing a reputation is knowing what there is to manage. Reputation management experts recommend that physicians conduct Google searches on themselves at least once a month, preferably more often. Things can spread quickly online, so seeing what content is there on a regular basis will help doctors stay ahead of a potential crisis. It's also a good way to see what positive things are being said about you, which you may be able to build on.

Steven Wyer, managing director of Reputation Advocate Inc. and author of the book Violated Online, said physicians should set up alerts on Google and Yahoo. These alerts work by registering keywords, such as a name, that the search engines will use to comb the Internet looking for any new mention of those keywords on blogs, websites, online forums and other sites. When it finds a new mention, it will send an email detailing where the keywords were mentioned, what was said and a link to the website.

The mistake many physicians make, however, is to not include all reasonable variations of their name in an alert, Wyer said. For example, John Smith, MD, could have several variations, including Dr. John Smith, Dr. John C. Smith, Dr. John Smith, MD, etc. Alerts for a handful of those variations should be set up.

Two: Correct mistakes and false information

The easiest places to start are websites that show up high in Google searches. Those sites are likely to be physician finder or rating sites or health plan physician finders. The sites often include wrong or outdated contact information and incomplete biographical and educational history.

Tuesday, September 27, 2011

Five months ago, Jamey Rodemeyer, a Buffalo junior high school student, got on his webcam and created a video urging other gay teenagers to remain hopeful in the face of bullying.

The 14-year-old spoke of coming out as bisexual and enduring taunts and slurs at school. And he described, in at times desperate tones, rejection and ridicule from other teenagers.

Jamey made the video as part of the It Gets Better project, a campaign that was started last fall to give hope to bullied gay teenagers. “All you have to do is hold your head up and you’ll go far,” he said. “Just love yourself and you’re set. … It gets better.”

But for Jamey, the struggle apparently was just too much. This week his parents announced that their son was found dead, an apparent suicide. He didn’t leave a note, but his parents said he had endured “constant taunting, from the same people over and over.” They added that his school had intervened to help, and that Jamey appeared to be benefiting from counseling.

News that a bullied teenager had succumbed to the very pressures he urged others to resist came as a shock to supporters of the It Gets Better project. And it provided a sobering reminder that bullied teenagers who appear to be adjusting may still be in trouble.

Dan Savage, the advice columnist and co-founder of It Gets Better, noted on his blog on Tuesday that Jamey’s death showed that “sometimes, the damage done by hate and by haters is simply too great.”

It sounds like Jamey had help — he was seeing a therapist and a social worker and his family was supportive — but it wasn’t enough. Whatever help Jamey was getting clearly wasn’t enough to counteract the hatred and abuse that he had endured since the fifth grade, according to reports, or Jamey’s fears of having to face down a whole new set of bullies when he started high school next year.

As suicides among lesbian, gay, bisexual and transgender teenagers have gotten more attention in the past year, researchers have sought to identify the factors that play the largest role. One study published in the journal Pediatrics in May, which looked at nearly 32,000 teenagers in 34 counties across Oregon, found that gay and bisexual teenagers were significantly more likely to attempt suicide than their heterosexual peers. The risk of an attempt was 20 percent greater among gay teenagers who lacked supportive social surroundings, like schools with gay-straight alliance groups or school policies that specifically protected gay, lesbian and bisexual students.

(HealthDay News) -- Although the U.S. Centers for Disease Control and Prevention reports that suicide is the third leading cause of death for people aged 15 to 24 years, a new study shows few suicidal teens are getting the mental health treatment they need.

The researchers found only 13% of teenagers with suicidal thoughts visited a mental health professional through their health care network, and only 16% received treatment during the year, even though they were eligible for mental health visits without a referral and with relatively low co-payments.

Even when researchers combined various types of mental health services, such as antidepressants and care received outside their health network, only 26% of teens contemplating suicide received help in the previous year.

"Teen suicide is a very real issue today in the United States. Until now, we've known very little about how much or how little suicidal teens use health care services. We found it particularly striking to observe such low rates of health care service use among most teens in our study," the study's lead author, Carolyn A. McCarty, of Seattle Children's Research Institute and research associate professor of pediatrics at the University of Washington School of Medicine, said in a Seattle Children's Hospital news release.

In the study, researchers analyzed the use of health care services among 198 teens ranging in age from 13 to 18 years. Half of the teenagers had had suicidal thoughts; the other half did not.

Although identifying teens with suicidal thoughts is critical, the researchers revealed mental health services were underused among all of the teens studied. Although 86% of the teens with suicidal thoughts had seen a health care provider, only 13% had seen a mental health specialist. Moreover, just 7% received antidepressants, the study found.

Monday, September 26, 2011

In U.S. Department of Health and Human Services’ annual report to Congress, Secretary Kathleen Sebelius reported that between Jan. 1, 2010, and Dec. 31, 2010, breaches involving 500 or more individuals were less than 1 percent of the breaches reported, but accounted for more than 99 percent of the more than 5.4 million individuals who were affected.

As part of the Health IT for Economic and Clinical Health (HITECH) Act, the HHS secretary is required to annually report to Congress on the number and nature of data breaches, and actions taken to respond to the breaches.

The number is growing because between Sept. 23, 2009, and Dec. 31, 2009, breaches involving 500 or more individuals were less than 1 percent, but accounted for more than 99 percent of the more than 2.4 million individuals affected by a breach of protected health information. The largest breaches occurred as a result of a theft, an error or failure to adequately secure protected health information. The greatest number of incidents resulted from human or technological error and involved the protected health information of just one individual, HHS’ report said.

The largest breaches in 2010, much like 2009, occurred as a result of a theft, HHS reported. However, compared with 2009, the number of individuals affected by the loss of electronic media or paper records containing protected health information in 2010 was greater than the number of individuals affected by unauthorized access or human error.

The report said the 2010 incidents involved an additional category, improper disposal of paper records by a covered entity or business associate. The greatest number of reported incidents in 2010 resulted from small breaches involving human or technological error, with the most common incidents involving protected health information of only one or two individuals.

HHS said in its report that the breach notification requirements are achieving their objectives: Increasing public transparency of breaches and increasing accountability of the covered entities.

The secretary indicated that covered entities and business associates are providing breach notifications. Millions of affected individuals are receiving notifications, local media are being notified in the regions affected, and the secretary is receiving breach reports. To provide increased public transparency, information about breaches involving 500 or more individuals is available on the Office of Civil Rights (OCR) website.

Also, the report said that more entities are taking remedial action to provide relief and mitigation to individuals and taking further action to prevent future breaches. In addition, OCR continues to exercise its oversight responsibility for reviewing and responding to and investigating breaches involving 500 or more individuals.

More than 250 breaches involving 500 or more individuals occurred in 2009 and 2010, and OCR has closed approximately 76 cases where it determined that the covered entity properly complied with the notification requirements, and corrective actions were taken. In the remaining cases, OCR continues to investigate and is working with the covered entities to ensure remedial action is taken to prevent future incidents.

For breaches involving less than 500 individuals, a covered entity must notify the secretary. HHS received approximately 5,521 reports of smaller breaches that occurred between Sept. 23, 2009, and Dec. 31, 2009. These smaller breaches affected approximately 12,000 individuals. HHS received more than 25,000 reports of smaller breaches occurring between Jan. 1, 2010, and Dec. 31, 2010. These smaller breaches affected more than 50,000 individuals.

The majority of the smaller breaches involved misdirected communications. Often, a clinical or claims record was mistakenly mailed or faxed to the wrong individual. In other instances, test results were sent to the wrong patient, files were attached to the wrong record, e-mails were sent to the wrong address and member ID cards were mailed to the wrong individuals. HHS said the covered entities reported fixing “glitches” in software that incorrectly compiled patient lists, revised policies and procedures, and trained or retrained employees who mishandled protected health information.

Sunday, September 25, 2011

The Obama administration escalated its crackdown on health-care fraud Wednesday, announcing charges against 91 people in eight cities who are accused of bilking the Medicare system out of nearly $300 million and victimizing the elderly and disabled people who rely on the federal insurance program.

Among those charged in the coordinated series of arrests was a doctor in Detroit who allegedly billed Medicare for services provided to dead people and claimed that he performed psychotherapy treatments more than 24 hours a day. Other doctors, nurses and health-care company owners were charged in various schemes to get paid for services that were medically unnecessary or never provided, officials said.

“From Brooklyn to Miami to Los Angeles, the defendants allegedly treated the Medicare program like a personal piggy bank,’’ Lanny A. Breuer, assistant attorney general for the Justice Department’s criminal division, said at a news conference in Washington.

It was unclear whether lawyers had been appointed for the defendants, 70 of whom were charged in indictments unsealed this week. The other 21 were charged in recent weeks. More than 55 defendants had been arrested by Wednesday afternoon, in addition to others who turned themselves in to authorities.

The arrests, announced by Attorney General Eric H. Holder Jr. and Health and Human Services Secretary Kathleen Sebelius, marked the latest step in a campaign against fraud that the administration calls a key part of its health-care reform agenda. The health-care overhaul law, President Obama’s signature domestic initiative, is an issue in the presidential campaign, but few have questioned the need to crack down on fraud.

In May 2009, the administration launched the Health Care Fraud Prevention and Enforcement Action Team to seek out illicit billing practices. That team’s Medicare Fraud Strike Force carried out the raids in cities that also included Houston, Baton Rouge, Dallas and Chicago.

In Miami, 45 defendants — including a doctor and a nurse — are accused of participating in $159 million worth of schemes to submit false Medicare billings for home health care and other services. Holder said the victims included “some of the most vulnerable among us — including seniors suffering from dementia and Alzheimer’s disease.’’

Officials said the crackdown will continue. “The health-care system is part of our nation’s infrastructure, and we must do everything in our power to protect the integrity of Medicare,” said FBI Executive Assistant Director Shawn Henry.

Saturday, September 24, 2011

TUESDAY, Sept. 6 (HealthDay News) -- The medical resident of today -- possibly your doctor in the future -- is exhausted, emotionally spent and likely stressed out about debt, a new study indicates.

"About 50% of our trainees are burned out," said study leader Dr. Colin P. West, an associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn.

Higher levels of stress translated into lower scores on tests that gauge medical knowledge and more emotional detachment, among other fallout.

The study is published in the Sept. 7 issue of the Journal of the American Medical Association, a themed issue devoted to doctors' training.

West and his team evaluated results of surveys and exams given to nearly 17,000 internal medicine residents, who were said to represent about 75% of all U.S. internal medicine residents in the 2008-9 academic year. The participants included 7,743 graduates of U.S. medical schools. They were asked about quality of life, work-life balance, burnout and their educational debt.

Among the findings:

Nearly 15% said their overall quality of life was "somewhat bad" or "as bad as it can be."

One-third said they were somewhat or very dissatisfied with work-life balance.

Forty-six percent said they were feeling emotionally exhausted at least once a week.

Nearly 29% said they felt detached or unable to feel emotion at least once a week.

More than half said they had at least one symptom of burnout.

The more educational debt the residents had incurred, the greater their emotional distress, the researchers found. Those with more than $200,000 of debt had a 59% higher chance of reporting emotional exhaustion, 72% greater likelihood of suffering burnout, and an 80% higher chance of feeling depersonalization.

Perhaps more alarming is the finding that greater stress was associated with lower test scores, and those students who were academically hurt by stress never caught up with their peers.

West said he can't explain why those more laden with debt are more stressed out. One possibility is that they may be more prone to stress to begin with.

Medical residents' stress has made news for years, and efforts are under way to improve their working conditions. However, West said, "to our knowledge, this is the first national study of residents' distress issues. And it's also the first national study to connect those issues to other important outcomes like medical knowledge."

As for solutions, he said "we have not yet identified the best ways to reduce burnout and promote well-being for residents, or for physicians in general."

He hopes that this new data, now gathered nationally, will help lead to solutions.

The findings come as no surprise to Dr. Peter Cronholm, an assistant professor of family medicine and community health and also a senior fellow at the Center for Public Health Initiatives of the University of Pennsylvania.

Cronholm, who published a study on resident burnout in 2008, said the residents of today may put more emphasis on work-life balance than previous generations.

One disturbing finding, he said, is that a stressed-out resident has less empathy over time. Already, close to one-third said they felt detached emotionally at least weekly.

However, he said, it's difficult to balance obligations to patients and get sufficient sleep and personal time. "Those two things sort of continue to compete with each other," he said.

Solutions aren't available yet, as "the problem is not yet totally understood. This is part of the conversation about health care reform," he said.

Friday, September 23, 2011

By Duff Wilson
The New York Times: Prescriptions - The Business of Health Care
Published September 15, 2011

Three journalism organizations on Thursday protested to the Obama administration a decision to pull a database of physician discipline and malpractice actions off the Web.

The National Practitioner Data Bank, created in 1986, is used by state medical boards, insurers and hospitals. The Public Use File of the data bank, with physician names and addresses deleted, has provided valuable information for many years to researchers and reporters investigating lax oversight of doctors, trends in disciplinary actions and malpractice awards.

On Sept. 1, responding to a complaint from Dr. Robert T. Tenny, a Kansas neurosurgeon, the Health Resources and Services Administration, an agency of the Department of Health and Human Services, removed the public use file from its Web site, said an agency spokesman, Martin A. Kramer. The agency also wrote a reporter a letter to warn he could be liable for $11,000 or more in civil fines for violating a confidentiality provision of the federal law. Both actions outraged journalism groups.

“Reporters across the country have used the public use file to write stories that have exposed serious lapses in the oversight of doctors that have put patients at risk,” Charles Ornstein, president of the Association of Health Care Journalists and a ProPublica reporter, said in an interview. “Their stories have led to new legislation, additional levels of transparency in various states, and kept medical boards focused on issues of patient safety.”

Two other national journalism organizations, Investigative Reporters and Editors and the Society of Professional Journalists, joined the health reporters’ group in the letter to Mary K. Wakefield, administrator of the federal office.

“If anything, the agency erred on the side of physician privacy,” they wrote.

Future doctors aren't learning much about the unique health needs of gays and lesbians, a survey of medical school deans suggests.

On average, the schools devoted five hours in the entire curriculum to teaching content related to lesbian, gay, bisexual and transgender patients, according to the survey results appearing in Wednesday's Journal of the American Medical Association. A third of the schools had none during the years students work with patients.

More than a quarter of the medical school deans said their school's coverage of 16 related topics was "poor" or "very poor." The topics included sex change surgery, mental health issues and HIV-AIDS.

While nearly all medical schools taught students to ask patients if they "have sex with men, women or both" while obtaining a sexual history, the overall curriculum lacked deeper instruction to help "students carry that conversation as far as it needs to go," said lead author Dr. Juno Obedin-Maliver of the University of California, San Francisco.

Without such education, doctors are left guessing and can make faulty assumptions, Obedin-Maliver said. For instance, lesbians need Pap tests, which screens for the sexually spread virus that causes most cervical cancer, as often as heterosexual women do. But some doctors assume they don't need them.

"I'm an ob-gyn and I have had lesbian patients come to me and say I haven't had a Pap test in 20 years because my doctors said I didn't need one," Obedin-Maliver said.

Earlier this year, the Institute of Medicine reported that there's little research to guide doctors in the treatment of lesbians and gays. But some things are known: There are increased risks of depression, suicide attempts, homelessness and being victims of violence for lesbians, gay men and bisexuals. Lesbians and bisexual women may get less preventive care to stay healthy, and have higher rates of obesity and breast cancer.

The Association of American Medical Colleges recommends that medical schools ensure students master "the knowledge, skills and attitudes necessary to provide excellent comprehensive care" for gay, lesbian, bisexual and transgender patients.

The new findings are based on a Web-based survey that drew responses from 85 percent of U.S. and Canadian medical schools.

That's a remarkably high response rate, which shows the deans believe it's an important issue, said Dr. Raymond Curry, vice dean for education at Northwestern University Feinberg School of Medicine in Chicago.

In an accompanying editorial, Curry wrote that the researchers missed the opportunity to find out how many medical schools have gay and lesbian faculty and how many have student groups for gays and lesbians.

"Trying to assess the adequacy of a curriculum in addressing these issues is perhaps not best approached in counting hours of instruction," Curry said.

Thursday, September 22, 2011

STORIES have been told about physicians who treat their own family members, but to the best of our knowledge, this practice has not been studied. Family members may benefit; they may avoid the inconvenience and expense of an office visit and gain an especially caring, available expert who is able to interpret medical language and help them maneuver through medical systems. Physicians may also benefit; accustomed to caring for patients and surrounded by books, tools, and pharmaceuticals, they may consider attending to ill family members a natural and rewarding opportunity.

Ethical questions have been raised, however, about physicians who treat members of their own families. McSherry found incomplete physical examinations, medical records, and immunizations to be undesirable consequences of physicians' treating their own children.1 The 1901 code of ethics of the American Medical Association (AMA) noted that a family member's illness "tends to obscure [the physician's] judgement and produce timidity and irresolution in his practice."2 In 1977, a revised admonition was dropped by the AMA with other "outmoded matters of medical etiquette."3In 1989, fearing financial abuse by unscrupulous providers, Medicare barred payment to physicians who care for "immediate family members."4

In this study, in an attempt to understand current practice, we asked these questions: Which family members request advice, diagnosis, or treatment? How do physicians respond to such requests? Which, if any, requests make physicians feel uncomfortable? And under what circumstances do physicians refuse requests from family members for medical assistance?

(Jump to the discussion)

DISCUSSION

To understand current norms, we gathered empirical data on which family members ask physicians for advice, diagnosis, or treatment and how physicians respond to these requests. We also attempted to understand the dilemmas inherent in this practice. In general, physicians reported providing services to relatives in proportion to how often and by whom they were asked.

Family Members' Requests

The services family members request and the services their physician relatives offer are probably different. Family members may request care that requires a complete history and physical examination, new knowledge, or facilities that are unavailable, thus sometimes embarrassing and frustrating their physician relatives. Conversely, many young children are simply given medical care by their parents. Although most respondents reported requests from their children, we did not distinguish among children's own requests, another parent's requests for them, and the physician parent's own wish to provide care.

Physicians' Responses

Caring for family members has advantages for patients with minor illnesses, especially when the physician is in primary care, although advantages for patients near the end of life have also been described.5 Recurrent problems such as conjunctivitis and pediatric pharyngitis are usually minor, have predictable courses, and may seem too trivial to trouble an unrelated doctor about. For all patients, our medical—financial complex is best negotiated by a strong patient advocate, conveniently located and readily accessible, who is both altruistic and self-interested.

The most important diagnoses physicians gave to family members ranged from trivial to grave. The breadth of these diagnoses and the relatively narrow range of operations performed suggest that personal, psychological, and familial factors contributed to the assessment of "most important." It is uncertain whether respondents made these diagnoses informally, as knowledgeable spouses (for example, a wife asks her physician husband about a breast lump she has found, which he then palpates), or formally, as attending physicians (a physician daughter takes her father's blood pressure regularly, reviewing his age, diet, weight, medications, electrocardiogram, and family history).

Sources of Discomfort

The central reason for physicians' refusal of and discomfort with requests appears to be missing medical information. About a third of the respondents mentioned colleagues who appeared to be inappropriately involved in the care of family members, describing the care provided as inadequate or contraindicated or reporting the obstruction of other providers' care. Respondents inferred that this poor quality of care resulted from their colleagues' closeness to the patient, but this inference may be scientifically unjustified. Comparative process and outcome evaluations of care provided to patients who are family members and to those who are not would permit a more complete assessment of the quality of care.

Our data suggest that along with limiting their active participation, physicians attempt to limit their emotional involvement in family members' care. Setting limits may reflect physicians' recognition of the emotional complexity of having dual roles,6 physicians' difficulty in providing reassurance when a serious illness is suspected,2 or the problems anticipated when there is a family relationship instead of a potentially therapeutic doctor–patient relationship.

Wednesday, September 21, 2011

Physicians are widely prescribing antipsychotics to people in nursing homes for off-label conditions such as dementia, and Medicare is largely picking up the bill, even though Medicare guidelines don't allow for off-label prescription reimbursements, according to an audit released in May by the U.S. Department of Health and Human Services Office of the Inspector General.

The findings underscore the fact that antipsychotics are often used when behavioral treatments would be more effective, psychologists say.

The office reviewed Medicare claims of people age 65 and older living in nursing homes in 2007—the most recent data at the time the study began—and found that 51 percent of all claims contained errors, resulting $116 million worth of antipsychotics such as Abilify, Risperdal and Zyprexa being charged to Medicare by people whose conditions didn't match the drugs' intended uses. Among the audit's findings are:

14 percent of the 2.1 million elderly people living in nursing homes use Medicare to pay for at least one antipsychotic prescription.

83 percent of all Medicare claims for antipsychotics are, based on medical reviews, prescribed for off-label conditions, specifically dementia.

22 percent of the claims for antipsychotics do not comply with the Centers for Medicare and Medicaid Services' guidelines outlining how drugs should be administered, including those guidelines stating that nursing home residents should not receive excessive doses and doses over excessive periods of time.

The report suggests that Medicare overseers reassess their nursing home certification processes and develop methods besides medical review to confirm that medications are prescribed for appropriate conditions.

Why such high rates of overprescription for antipsychotics? HHS Inspector General Daniel Levinson argued in the report that pharmaceutical companies' marketing tactics are often to blame for antipsychotics' overprescribing. Victor Molinari, PhD, a geropsychologist at the University of South Florida in Tampa, says that another important issue is the dearth of psychologists trained to provide behavioral interventions to people in nursing homes. While he agrees that people in nursing homes are taking too much antipsychotic medication, he believes nursing home physicians are often responding to a lack of options.

Many nursing home administrators are quite savvy in their mental health knowledge and would prefer to offer their residents the option of behavioral treatments, Molinari says, but when residents need immediate calming, physicians will turn to antipsychotic medication because it's quick and available. Additionally, he says, many nursing home staff aren't educated enough about nonmedical options, so they go straight for the antipsychotics.

"It follows the saying, 'If your only tool is a hammer, everything is a nail,'" he says. "Nursing homes are not just straitjacketing residents with medications as a matter of course, but because there are a host of barriers to giving them optimal care."

Tuesday, September 20, 2011

David Scratchley is not all he claimed to be, though it wouldn't be apparent if you followed his career.

The head of a Seattle drug-treatment center, Scratchley authored books, gave speeches to city employees and co-hosted a radio show. He has worked in the Seattle area at least 23 years and is regarded as a local expert on substance abuse and addictions.

David Scratchley

Scratchley, 52, flatly claimed in a recent video to be a psychologist.

He is not.

He is training to be certified by the state as a chemical-dependency counselor, according to the Department of Health.

That's just one of the mysteries and exaggerations that surround Scratchley, who was arrested early Friday and has been held without bail at the King County Jail on investigation of attempted rape of a child in the first degree and communicating with a minor for immoral purposes.

According to Seattle police, Scratchley talked with a woman about raping a 10-year-old boy at his Belltown apartment on Thursday.

The woman, who said she met Scratchley through drug treatment, contacted police Thursday afternoon after being fearful that Scratchley planned to go ahead with the sexual assault.

Police found the child inside Scratchley's apartment building and took him to Harborview Medical Center; investigators did not say whether the child had been harmed. They also found suspected cocaine in the apartment, according to a Seattle police report.

King County prosecutors said that Wednesday is their deadline to file charges against Scratchley in Superior Court.

The state Department of Health opened an investigation of Scratchley on Tuesday because of media attention surrounding his arrest, though department officials said they have never received a complaint about him.

One thing the health department will focus on is Scratchley's claim he is a psychologist.

Scratchley, clinical manager of the treatment program at the Matt Talbot New Hope Recovery Center, has never been a licensed psychologist in the state of Washington, according to Department of Health officials and records.

There is no gray area when it comes to making such a claim, said Betty Moe, a department program manager. State law prohibits anyone from calling themselves a psychologist unless they've obtained such a credential from the Department of Health.

Monday, September 19, 2011

Three hundred and fifty thousand: That's a conservative estimate for the number of offenders with mental illness confined in America's prisons and jails.

More Americans receive mental health treatment in prisons and jails than in hospitals or treatment centers. In fact, the three largest inpatient psychiatric facilities in the country are jails: Los Angeles County Jail, Rikers Island Jail in New York City and Cook County Jail in Illinois.

"We have a criminal justice system which has a very clear purpose: You get arrested. We want justice. We try you, and justice hopefully prevails. It was never built to handle people that were very, very ill, at least with mental illness," Judge Steve Leifman tells Laura Sullivan, guest host of weekends on All Things Considered.

A failing system

When the government began closing state-run hospitals in the 1980s, people with mental illness had nowhere to turn; many ended up in jail. Leifman saw the problem first-hand decades ago in the courtroom. When individuals suffering from mental illness came before him accused of petty crimes, he didn't have many options.

"What we used to do, which I tell people was the definition of insanity [...] was they would commit an offense, the police would arrest them, they'd come to court, they'd be acting out so we would order two or three psychological evaluations at great expense, we would determine that they were incompetent to stand trial and we'd re-release them back to the community and kind of held our breath and crossed our fingers and hoped that somehow they'd get better and come back and we could try them," he says.

Instead, many disappeared and got re-arrested. Sometimes within minutes.

"They'd walk out the door, they were ill, they'd act out, because [the jail] is next to the courthouse there are several officers out there, and they'd get re-arrested," he says.

Not only was the system inefficient, it was costly as well. When Leifman asked the University of South Florida to look at who the highest users of criminal justice and mental health services in Miami-Dade County, researchers found the prime users were 97 people, individuals diagnosed primarily with schizophrenia.

"Over a five-year period, these 97 individuals were arrested almost 2,200 times and spent 27,000 days in the Miami-Dade Jail," Leifman says. "It cost the tax payers $13 million."

Sunday, September 18, 2011

A Washington state social worker is circulating a petition urging federal lawmakers and the military to adopt a policy declaring that service members shouldn't be punished if they seek help for behavioral health issues, such as post-traumatic stress.

Patricia Bailey, 45, believes the lack of a firm policy on whether service members could be held back in their careers for seeking counseling is one of the main obstacles keeping people in the military from pursuing treatment.

"It will give reassurance to him that if he seeks mental health counseling nothing will be in jeopardy," said Bailey, whose 13-year marriage to a Joint Base Lewis-McChord soldier ended in 2008 as stress built during his deployments to Iraq.

She's targeting a gray area in the military's evolving suicide prevention and post-traumatic stress programs. Leaders at the Pentagon and at Lewis-McChord insist service members won't face professional repercussions for seeking counseling, but it's not clear how well that message reaches down the ranks.

An April study on military suicides released by the nonprofit RAND Corporation pointed out that the Defense Department hasn't taken concrete steps to reverse a perception that service members might be retired for medical reasons or lose out on a promotion if they ask for counseling. The study received funding from the Defense Department.

Bailey got a close view of Lewis-McChord's behavioral health services both as a part-time counselor between 2002 and 2004 and as someone who later reached out for help in keeping her marriage together. She'd like to see a greater emphasis on preventive programs instead of ones that kick in after an outburst, such as an arrest.

"When my husband and I were going through everything, I asked people for help," she said. "I wasn't shy. And they said 'We can't do anything for you.' You're frustrated because you can't do anything. I didn't want my marriage to end."

She's one of many people in the South Sound who are raising their voices to draw attention to the psychological toll 10 years of warfare have taken on military families. In the past year, service clubs have organized retreats for Army couples and the United Way of Pierce County put forward a proposal to deliver more resources to military families.

The military, likewise, is looking for new approaches. Madigan Army Medical Center increased its ranks of behavioral health specialists last year. Lewis-McChord recently hired a new suicide prevention officer.
Yet the Army and the base continue to struggle with how to reach distressed service members.

The Army reported that it was investigating 32 possible suicides in July, the most in any month over the past two years. Lewis-McChord officials told Sen. Patty Murray, D-Wash., that nine soldiers took their lives this year.